Changes

May 2026 — minor update. Dosing for phenoxymethylpenicillin amended.

Update

Goals

To support primary healthcare professionals to:

• Make a diagnosis of the likely cause of a sore throat.
• Offer advice on alleviation of symptoms.
• Prescribe treatment where appropriate.
• Refer to secondary care if necessary.

Outcome measures

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

QIPP - options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

What is it?

• Sore throat occurs when an acute upper respiratory tract infection affects the mucosa of the throat.
• Clinical descriptions of acute sore throat include:
  • Acute pharyngitis: inflammation of the part of the throat behind the soft palate (oropharynx).
  • Tonsillitis: inflammation of the tonsils. May occur in isolation or as part of a generalised pharyngitis.

[Kenealy, 2014; BMJ Best Practice, 2023a; BMJ Best Practice, 2023b]

What causes it?

• Acute sore throat is most commonly due to viral organisms [BMJ Best Practice, 2023a].
• Common infectious causes of acute sore throat include [Kenealy, 2014; BMJ Best Practice, 2023a]:
  • Rhinovirus, coronavirus, parainfluenza virus.
  • Influenza types A and B.
  • Streptococcal infection.
    • Group A beta-haemolytic streptococcus (GABHS), also known as Streptococcus pyogenes, is the most common bacterial cause of sore throat and may cause pharyngitis, tonsillitis, or scarlet fever.
    • Group C and G beta-haemolytic streptococci may cause pharyngitis and tonsillitis and have been associated with food-borne outbreaks of pharyngitis.
  • Adenovirus, leading to pharyngoconjunctival fever.
  • Herpes simplex virus type 1 (and more rarely type 2), leading to acute herpetic pharyngitis.
  • Epstein-Barr virus, leading to infectious mononucleosis (glandular fever).
  • Fusobacterium necrophorum, which may cause pharyngitis or tonsillitis, and can (very rarely) lead to Lemierre syndrome (septic phlebitis of the internal jugular vein). 
• Rarer infectious causes include [Kenealy, 2014; BMJ Best Practice, 2023a]:
  • Haemophilus influenza type b — can cause epiglottitis.
  • Enteroviruses — can cause herpangina and hand, foot, and mouth disease.
  • Measles virus.
  • Candida albicans — causes candidal pharyngitis. May be more common in immunocompromised people, including those undergoing chemotherapy and/or oropharyngeal irradiation.
  • Neisseria gonorrhoeae — can cause gonococcal pharyngitis.
  • Corynebacterium diphtheria, C. ulcerans — cause diphtheria.
  • Arcanobacterium haemolyticum — causes arcanobacterial pharyngitis.
  • Yersinia enterocolitica — causes yersinial pharyngitis.
  • Francisella tularensis — causes oropharyngeal tularaemia.
  • Chlamydophila pneumoniae, Mycoplasma pneumonia — can cause chlamydial pharyngitis and mycoplasmal pharyngitis.
  • HIV-1.
• Non-infectious causes are uncommon, and include [Kenealy, 2014]:
  • Physical irritation (e.g. from a nasogastric tube or from smoke).
  • Hayfever.
  • Gastro-oesophageal reflux disease.
  • Kawasaki disease — usually presents with fever and the diagnosis is established on the presence of clinical criteria. Throat symptoms may occur.
  • Oral mucositis secondary to radiotherapy or chemotherapy, which may become secondarily infected.
  • Haematological disorders [Viani and Donnelly, 1998]:
    • Leukaemia: ulceration and haemorrhage of the mucous membrane of the pharynx may occur.
    • Aplastic anaemia: sloughing and ulceration of the mouth and pharynx may occur.
  • Drugs which can cause blood disorders (e.g. neutropenia, agranulocytosis, thrombocytopenia) leading to infection and acute sore throat. These include cytotoxic drugs, carbimazole, clozapine, and sulfasalazine  [BNF, 2023].

How common is it?

• Sore throat is a common condition. In a survey study conducted in Scotland, 31% of adults reported a severe sore throat in the previous year, with 38% of these people visiting a doctor [Kenealy, 2014].
• It is estimated that an average-sized UK general practice, with a list size of 7,000 patients, will have around 550 consultations for sore throat each year [Guillford, 2016].
• The highest incidence is in children during the winter months [BMJ Best Practice, 2023a].
• Recurrent sore throat has an incidence in general practice in the UK of 100 per 1,000 population per year [Georgalas et al, 2014].
• Bacterial pharyngitis is more common in winter (or early spring), while enteroviral infection is more common in the summer and autumn [BMJ Best Practice, 2023a].
• Colonisation with group A Streptococcus (leading to pharyngitis) reaches its peak in school-aged children (up to 20%) during the winter months. However, group A Streptococcus infection typically accounts for less than one third of all cases of acute pharyngitis [BMJ Best Practice, 2023a].

What are the complications?

• Complications of streptococcal pharyngitis/tonsillitis are rare.
  • Scarlet fever is simply the presence of a characteristic 'scarlatina' rash due to infection with an erythrogenic toxin-producing strain of streptococci (usually group A but also can be type B or C).
  • Suppurative complications include:
    • Otitis media (most common).
    • Acute sinusitis — rare, occurring in approximately 0.4% of untreated cases within 2 weeks of an acute tonsilitis.
    • Peri-tonsillar abscess (quinsy) — occurs in approximately 2% of cases within 2 months of an acute tonsilitis, and can pose a risk of airway compromise, aspiration of pus, and death due to vascular involvement. 
  • Non-suppurative complications include acute rheumatic fever, acute glomerulonephritis and reactive arthritis, although these are rare in developed countries.
• Pharyngitis/tonsillitis as a result of Fusobacterium necrophorum infection can (very rarely) lead to Lemierre disease (sepsis and jugular vein thrombosis). 

[Georgalas et al, 2014; Kenealy, 2014; BMJ Best Practice, 2023a; BMJ Best Practice, 2023b]

What is the prognosis?

• Sore throat due to a viral or bacterial cause is a self-limiting condition which generally resolves within two weeks [Georgalas et al, 2014; Kenealy, 2014; BMJ Best Practice, 2023a]:
  • A sore throat will spontaneously resolve by 3 days in about 40% of people.
  • By 1 week, approximately 85% of people are symptom-free. 
• The symptoms of infectious mononucleosis usually resolve within 1–2 weeks although mild cases may resolve within days. However lethargy continues for some time afterwards and in rare cases may continue for months or years [Rezk, 2015; De Paor, 2016].

How do I diagnose the cause of a sore throat?

Note: There is no evidence that sore throats caused by bacterial infection are more severe than those caused by viral infection, or that the duration of the illness is significantly different in either case. The precise diagnosis may be clinically significant in more severe cases or of epidemiological interest. 

To identify the underlying cause of a sore throat:

• Examine the person's throat and neck:
  • Pharyngitis is often associated with pharyngeal exudate and cervical lymphadenopathy.
  • Tonsillitis is associated with tonsillar exudate with enlargement and erythema of the tonsils. There may be anterior cervical lymphadenopathy.
• Ask the person about their symptoms. Non-specific symptoms may include:
  • Headache, nausea, vomiting, and abdominal pain — may be present in children with pharyngitis, and all people with tonsillitis.
  • Fever — this is common in pharyngitis and tonsillitis. Most people with acute tonsillitis have a fever over 38°C.
  • Note: Rhinorrhoea, nasal congestion, and cough are usually present in viral pharyngitis, but not in bacterial pharyngitis.
• Be aware that a sore throat may occasionally result in significantly reduced fluid intake, which may lead to dehydration.
  • Ask the person about recent fluid intake if pain on swallowing is significant.
  • For babies and young children, ask the parent/carer about the number of wet nappies, whether fluid intake is significantly reduced (50-75% normal volume) and examine the child for signs of clinical dehydration (reduced skin turgor and/or a capillary refill time of more than three seconds, and/or dry mucous membranes).
• Consider the person's signs and symptoms, and use the FeverPAIN or Centor clinical prediction score to determine the likelihood of streptococcal infection (and therefore the need for antibiotic treatment):
  • Acute Group A streptococcal (GAS) pharyngitis/tonsillitis is common in children and adolescents aged 5 to 15 years and is more common in the winter (or early spring) in temperate climates.  Streptococcal infection is suggested by fever over 38.5°C, exudate on the pharynx/tonsils, anterior neck lymphadenopathy, and absence of cough. A scarlatiniform rash may be present, especially in children. For more information, see the CKS topic on Scarlet fever.
  • The FeverPAIN criteria: score 1 point for each (maximum score of 5).
    • Fever (during previous 24 hours). 
    • Purulence (pharyngeal/tonsillar exudate).
    • Attend rapidly (within 3 days after onset of symptoms).
    • Severely Inflamed tonsils.
    • No cough or coryza.
  • A score of 0 or 1 is associated with a 13-18% likelihood of isolating streptococcus. A score of 2 or 3 is associated with a 34-40% likelihood of isolating streptococcus. A score of 4 or 5 is associated with a 62-65% likelihood of isolating streptococcus.
  • Centor criteria: score 1 point for each (maximum score of 4).
    • Tonsillar exudate.
    • Tender anterior cervical lymphadenopathy or lymphadenitis.
    • History of fever (over 38°C).
    • Absence of cough.
  • A score of 0, 1 or 2 is thought to be associated with a 3-17% likelihood of isolating streptococcus. A score of 3 or 4 is thought to be associated with a 32-56% likelihood of isolating streptococcus.
  • NICE do not recommend the use of rapid antigen testing. 
• Other common (non-streptococcal) infectious causes of acute sore throat, and their signs and symptoms include:
  • The common cold — suggested by rhinorrhoea, nasal congestion, and cough.  For more information, see the CKS topic on the Common cold.
  • Influenza — suggested by headache, weakness and fatigue, myalgia, malaise, anorexia, insomnia, a dry, unproductive cough, and fever. For more information, see the CKS topic on Influenza - seasonal.
  • Pharyngoconjunctival fever — suggested by fever and conjunctivitis. Malaise, myalgia, headache, rhinitis and cervical adenitis may also be present.
  • Acute herpetic pharyngitis — suggested by vesicles and shallow ulcers on the palate (although these are not always present). There may be cervical lymphadenopathy, fever, and exudate. If there is an associated gingivostomatitis, vesicles and ulcers are also present on the labial and buccal mucosa. For more information, see the CKS topic on Herpes simplex - oral.
  • Infectious mononucleosis (glandular fever) — suggested by pharyngitis of longer than several days' duration, adenopathy, and splenomegaly. A serum monospot test should be carried out to confirm the diagnosis (in people over 4 years of age) and full blood count should also be considered — a raised WBC count with lymphocytosis and atypical lymphocytes is suggestive of infectious mononucleosis. For more information, see the CKS topic on Glandular fever (infectious mononucleosis).
  • COVID-19 — suggested by fever, a new continuous cough, shortness of breath, malaise, muscle aches and pains, rhinorrhoea and gastrointestinal symptoms. For more information, see the CKS topic on Coronavirus - COVID-19.
• Rarer infectious causes of sore throat include:
  • Herpangina — suggested by acute onset of fever, sore throat, and dysphagia, and also vomiting and abdominal symptoms. Small vesicles (1–2 mm) may be seen on the soft palate, fauces, palate, uvula, and tonsils, which rupture to become small white ulcers. The condition usually affects people of 2–20 years of age and most commonly occurs in the late summer and autumn.
  • Hand, foot, and mouth disease — suggested by fever (typically 38–39°C), malaise, loss of appetite, cough, abdominal pain, and sore mouth that precede the development of tender lesions in the mouth and/or vesicles on the palms of the hands and soles of the feet. Children younger than 4 years of age are most commonly affected and it most commonly occurs in the late summer and autumn. For more information, see the CKS topic on Hand foot and mouth disease.
  • HIV-1— sore throat may be a feature of primary HIV infection and occurs after an incubation period of 3–5 weeks, with myalgia, arthralgia, lethargy, and in some people a non-itchy maculopapular rash. Lymphadenopathy develops a week later. For more information, see the CKS topic on HIV infections and AIDS.
  • Gonorrhoea — causes mild pharyngitis which may be accompanied by anterior cervical adenopathy. Should be considered in sexually active or abused individuals with pharyngitis, especially in those with negative cultures for GAS. Take throat swabs for culture to confirm the diagnosis. For more information, see the CKS topic on Gonorrhoea.
  • Diphtheria — consider if oropharyngeal membranes appear grey/green, and/or the person has not been vaccinated. Take throat swabs for culture to confirm the diagnosis. 
  • Measles —  suggested by conjunctivitis, rhinitis, cough, and characteristic maculopapular rash in a person who is non-vaccinated. Koplik spots (bluish-white, raised lesions on an erythematous base on the buccal mucosa) are characteristic. 
  • Arcanobacterial pharyngitis —  suggested by a diffuse, sometimes itchy, erythematous maculopapular rash on the extremities and trunk. Pharyngeal exudate and cervical lymphadenopathy are commonly present.
  • Yersinial pharyngitis — this is associated with contaminated food and drink, but in adults may occur without gastrointestinal symptoms. Rarely, there may be a fulminant course with a high mortality rate. Fever, prominent cervical lymphadenopathy, and abdominal pain with or without diarrhoea have been reported.
  • Tularaemia — may be suggested by pharyngeal ulceration and exudate, and a history of ingestion of undercooked wild animal meat. The pharyngitis may have previously failed to respond to penicillin. Take throat swabs for culture to confirm the diagnosis. 
  • Chlamydial pharyngitis, mycoplasmal pharyngitis— may occur in association with pneumonia or bronchitis but otherwise have no clear distinguishing features. Chlamydial pharyngitis should be considered in sexually active or abused individuals with pharyngitis, especially in those with negative cultures for GAS. Take throat swabs for culture to confirm the diagnosis. For more information, see the CKS topic on Chlamydia - uncomplicated genital.
  • Candida albicans — may cause pharyngitis in immunosuppressed individuals, people who use inhaled corticosteroids, or those undergoing chemotherapy or irradiation for oropharyngeal cancer.
  • Retropharyngeal or peritonsillar abscess — may present with sore throat, fever, neck pain and muffled voice, and is most common in children 2 to 4 years old, or older children with a history of oral or pharyngeal trauma.
• Non-infectious causes include:
  • Physical irritation — consider in people with a nasogastric tube, or who smoke.
  • Hayfever. For more information, see the CKS topic on Allergic rhinitis.
  • Gastro-oesophageal reflux disease. For more information, see the CKS topic on Dyspepsia - proven GORD.
  • Kawasaki disease — may occasionally present as sore throat without exudate. The cause of Kawasaki disease is unknown. The majority of cases occur in children under 4 years of age. Kawasaki disease is diagnosed by the presence of either five of the six main symptoms, or four main symptoms if coronary aneurysms are identified by echocardiography. The six main symptoms are:
    • Fever of unknown aetiology lasting 5 days or more.
    • Bilateral conjunctivitis.
    • Changes in the lips and oral cavity (dryness and fissuring of the lips, and redness of the oral cavity and pharynx).
    • Cervical lymphadenopathy.
    • Polymorphous rash (a combination of morbilliform, scarlatiniform, urticariform, or erythema multiforme-like rash).
    • Changes in the extremities (reddening of the palms and soles, desquamation of the skin, and oedema of the hands and feet).
  • Oral mucositis secondary to radiotherapy or chemotherapy, which may become secondarily infected. For more information see the CKS topic on Palliative care - oral.
  • Haematological disorders: 
    • Leukaemia: ulceration and haemorrhage of the mucous membrane of the pharynx may occur. For more information, see the CKS topic on Haematological cancers - recognition and referral.
    • Aplastic anaemia: sloughing and ulceration of the mouth and pharynx may occur.
  • Drugs that can cause blood disorders (e.g. neutropenia, agranulocytosis, thrombocytopenia) leading to infection and acute sore throat. These include cytotoxic drugs, carbimazole, clozapine, and sulfasalazine.
  • Oropharyngeal cancer — suggested by hoarseness, dysphonia, sore throat, difficulty swallowing, and neck mass or adenopathy.
  • Behcet's syndrome — suggested by vesicles on pharynx, genital ulcers, skin and eye lesions.
  • Steven's Johnson syndrome — suggested by vesicles on pharynx, along with more pronounced mucosal changes in a person with recent infections, seizures, or new medications.
• Be alert for serious underlying causes/complications that can be associated with sore throat, including:
  • Epiglottitis — suggested by severe and acute onset of sore throat and fever, muffled voice, drooling, and stridor.
    • A child with epiglottitis prefers to sit leaning forward. Breathing tends to be tentative and careful, without marked increase in respiration rate. Inspiratory stridor and hoarseness may occur. Tachycardia may be out of proportion to the fever if hypoxia is present.
    • In adults, predictors of airway compromise include sitting erect, stridor, and dyspnoea.
    • Note: Do not examine the throat of anyone with suspected epiglottitis as this may precipitate closure of the airway.
  • Peritonsillar abscess (quinsy) — suggested by fever, neck pain, trismus, a muffled voice, a displaced uvula, and an enlarged, displaced tonsil, with swelling of the peri-tonsillar region. It is most common in children 2 to 4 years of age.
  • Retropharyngeal abscess — suggested by severe sore throat that does not resolve after a few days. There may be trismus or visible neck swelling.
  • Lemierre syndrome — thrombophlebitis of the jugular vein. Typically seen in people with systemic inflammatory response syndrome (SIRS) or sepsis.

Scenario: Management

From birth onwards.

Paracetamol and ibuprofen

For detailed prescribing information on paracetamol and ibuprofen, see the CKS topics on Analgesia - mild-to-moderate pain and NSAIDs - prescribing issues.

Clarithromycin and erythromycin

Phenoxymethylpenicillin

Search strategy

Scope of search

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of acute sore throat.

Search dates

July 2017 - January 2023

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline.

• exp pharyngitis/, exp tonsilitis/, exp pharynx/, exp adenoids/., exp tonsillectomy/, tonsil$.tw., pharyn$.tw., adenoid$.tw., exp acute pain/, (acute ADJ sore throat).tw., pain.tw., sore throat.tw.

Sources of guidelines

• National Institute for Health and Care Excellence (NICE)
• Scottish Intercollegiate Guidelines Network (SIGN)
• Royal College of Physicians
• Royal College of General Practitioners
• Royal College of Nursing
• NICE Evidence
• World Health Organization
• Guidelines International Network
• TRIP database
• Agency for Healthcare Research and Quality
• National Health and Medical Research Council (Australia)
• Royal Australian College of General Practitioners
• British Columbia Medical Association
• Canadian Medical Association
• Alberta Medical Association
• Michigan Quality Improvement Consortium
• Singapore Ministry of Health
• National Resource for Infection Control
• RefHELP NHS Lothian Referral Guidelines
• Medline (with guideline filter)
• Driver and Vehicle Licensing Agency
• NHS Health at Work (occupational health practice)

Sources of systematic reviews and meta-analyses

• The Cochrane Library:
  • Systematic reviews
  • Protocols
  • Database of Abstracts of Reviews of Effects
• Medline (with systematic review filter)
• EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

• NIHR Health Technology Assessment programme
• The Cochrane Library:
  • NHS Economic Evaluations
  • Health Technology Assessments
• Canadian Agency for Drugs and Technologies in Health
• International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

• The Cochrane Library:
  • Central Register of Controlled Trials
• Medline (with randomized controlled trial filter)
• EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

• Drug and Therapeutics Bulletin
• TRIP database
• Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

• Department of Health
• Health Management Information Consortium (HMIC)

Patient experiences

• Healthtalk
• BMJ - Patient Journeys

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

• British National Formulary (BNF)
• electronic Medicines Compendium (eMC)
• European Medicines Agency (EMEA)
• Medicines and Healthcare products Regulatory Agency (MHRA)
• REPROTOX
• Scottish Medicines Consortium
• Stockley's Drug Interactions
• TERIS
• TOXBASE
• Micromedex
• UK Medicines Information

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

• Clinical accuracy.
• Consistency with other providers of clinical knowledge for primary care.
• Accuracy of implementation of national guidance (in particular NICE guidelines).
• Usability.

Principles of the consultation process

• The process is inclusive and any individual may participate.
• To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
• Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
• Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
• External reviewers are not paid for commenting on the draft topics.
• Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
• All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
• All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

• Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
• Stakeholders identified from the following groups are invited to review draft topics:
  • Experts in the topic area.
  • Professional organizations and societies (for example, Royal Colleges).
  • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
  • Guideline development groups where the topic is an implementation of a guideline.
  • The British National Formulary team.
  • The editorial team that develop MeReC Publications.
• Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

• Topic selection
• Scoping of topic
• Selection of clinical scenarios
• First draft internal review
• Second draft internal review
• External review
• Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

• Animal studies
• Original research is not written in English

Possible exclusions for reviewed literature:

• Sample size too small or study underpowered
• Bias evident or promotional literature
• Population not relevant
• Intervention/treatment not relevant
• Outcomes not relevant
• Outcomes have no clear evidence of clinical effectiveness
• Setting not relevant
• Not relevant to UK
• Incorrect study type
• Review article
• Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

• Feasibility
  • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
• Organizational and Financial Impact Analysis
• Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
  • Eligible population
  • Current interventions
  • Likely uptake of new intervention or recommendation
  • Cost of the current or new intervention mix
  • Impact on other costs
  • Condition-related costs
  • In-direct costs and service impacts
  • Time dependencies
• Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

• Personal financial interests
• Personal family interest
• Personal non-financial interest
• Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.